Metropolis Rehab & Hcc

F 0550 Level of Harm - Actual harm

On 10/22/25 at 12:29 PM, V1 (Administrator) stated she would expect staff members to store their personal belongings in the locker rooms or in the break room. V1 stated she would not expect for staff to store their personal items in a resident's closet. V1 stated she does not believe it is right for staff members to store their personal items in a resident's room.

Residents Affected - Few

On 10/22/25 at 12:45 PM, the men's and women's locker rooms were observed to have lockers for use by staff members that could be locked.

The facility's undated Residents' Rights policy documents a resident has the right to make personal decisions, right to privacy, and the right to be treated with consideration, respect, and dignity.

The Ombudsman's Residents' Rights pamphlet with a revised date of 11/18 documents the resident has a general right to privacy and confidentiality. The pamphlet states a resident has a right to keep and use their own property.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Metropolis Rehab & Hcc

2299 Metropolis Street Metropolis, IL 62960

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

they run out of towels and washcloths and when they do they report it to the nurse. V42 stated they run out of wipes and incontinence briefs, and she had not been told to use pull ups instead of briefs. V42 stated

she uses the next closest size for the residents when she doesn't have the appropriate size.On 10/20/25 at 3:45 PM, V19 (CNA) stated they don't have enough briefs to meet the needs of the residents. V19 stated

they had pull ups to use in place of them. V19 stated that is like putting a pull up on a baby who needs a diaper. V19 stated they use them, but it isn't what the resident needs. V19 stated if someone is incontinent but ambulatory they would need a pull up, however if someone is incontinent and not ambulatory, they would need a brief. V19 stated each residents plan of care should describe the type of incontinence supply

they need.On 10/22/25 at 11:33 A.M., V48 (CNA) stated the facility has been short on supplies lately including incontinence briefs. V48 stated the facility will have large amount of one size and none of another.

V48 stated this has happened periodically over the past two months. V48 stated she reported it to administration in the past who tell her the supplies are on back order. V48 stated administration told her

they would go to the store and get the supplies needed, but she is unsure whether they did or not.On 10/22/25 at 11:45 A.M., V47, CNA stated the facility has been short on supplies including incontinence briefs, cleansing wipes, towels, and washcloths. V47 stated when they are short on supplies, they use the next most appropriate size. V47 stated the problem with not using the appropriate size brief is if the brief is too large urine or feces will leak, and if they are too small, they cause skin irritation. V47 stated she has reported the lack of supplies to V2, DON. V47 stated she has worked at times when the CNA staff have been out of washcloths and cleansing wipes both, and the CNAs had to cut up towels to make washcloths.

V47 stated the facility had been dealing with short supplies periodically for approximately 6 months.On 10/22/25 at 12:13 P.M., V2, DON stated she doesn't see a concern with using pull ups in place of briefs if

the CNA staff are doing their bed checks like they are supposed to. V2 stated she was unsure though if a resident had an incontinence episode immediately after being changed if a pull up could absorb all the wetness from urine or feces that increases risk of skin break down.The facility Grievance Form dated 8/6/25 documents, .Description: Staff have not had towels for showers for two mornings. Below To Be Completed By Staff, Investigation: I found some bath towels (and) washcloths in (name of resident) old room yesterday.

Summary/Findings: I found some washcloths in the room between big n (sic) small shower rooms. Then I also found some washcloths in room [ROOM NUMBER]B closet earlier. I found a bath towel (and) another washcloth in 402A bed (and) bathroom when I deep cleaned. Recommendations/Action Taken: Spoke with (name of Laundry Supervisor) to ensure laundry is being completed in the evening as scheduled. New towels (and) washcloths ordered. Date Resolved: 8/7/25. Person Notified of Resolution: Staff.On 10/22/25 at 12:29 P.M., V1, Administrator (ADM) stated she was not aware of the facility being out of any supplies except cleansing wipes one time. V1 stated the one time the facility ran out of cleansing wipes someone from administration went to a local department store and purchased some. V1 stated the facility's regular order person had been out on maternity leave. V1 denied ever being out of washcloths or towels. V1 stated

she believed the reason staff say they are out of them is because they don't want to go back to laundry to look for them. V1 stated regarding the resident grievance filed on 8/26/25 on behalf of staff regarding towels and washcloths it was because the resident's family wanted thicker ones, not because the facility was out of them. V1 stated there is no facility policy regarding towels.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Metropolis Rehab & Hcc

2299 Metropolis Street Metropolis, IL 62960

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

showers to stay warmer.On 10/20/25 at 1:16 PM, Resident R25's nails were long and Resident R25 had a large amount of dark debris under his nails.On 10/23/25 at 10:40 AM, Resident R25's room was 77 degrees Fahrenheit when measured with an infrared thermometer gun. At that time Resident R25 stated, his room was comfortable to him at that time. Resident R25 was wearing long pants, a long sleeve shirt, and a flannel shirt over the long sleeve shirt. 3. Resident R3's admission Record documents an admission date of 05/14/24 with diagnoses including: Alzheimer's disease with late onset, dementia, chronic obstructive pulmonary disease, acute and chronic respiratory failure with hypoxia, pleural effusion, abnormal posture, and body mass index 19.9 or less.Resident R3's minimum data set (MDS) dated [DATE REDACTED] documents a dash for the question, should brief interview for mental status be conducted ? and a dash for the BIMS summary score. Resident R3's care plan documents a focus area documenting: care/ADL preferences dated 09/26/24 with an intervention listed as: I (Resident R3) prefer to have my room at a warmer temperature dated 09/26/24. Resident R3's care plan documents a focus area documenting: Resident R3 has an ADL self-care performance deficit related to dementia dated 05/14/14 with an intervention listed as: Bathing: the resident requires 1 staff participation with bathing dated 05/14/24. On 10/23/25 at 10:22 PM, Resident R3's room was 75 degrees Fahrenheit when taked with and infrared thermometer gun. Resident R3 said yes when asked if she was comfortable, Resident R3 stated no when asked if she was cold and stated no when asked if she was hot. Resident R3 was wearing a sweatshirt and sweatpants and Resident R3 was covered with a blanket. On 10/23/25 at 3:40 PM, V16 (Family) stated, Resident R3 gets cold easily, V16 stated, she has told the CNA's the shower room is too cold for Resident R3. V16 has stated, she has went down to the shower room before and she thought it was cool, especially for a small older person that is wet from a shower and has asked why they could not make it warmer in the room. V16 stated she has never received an answer. 4. Resident R6's admission Record documents

an admission date of 02/06/25 with diagnoses including: acute respiratory failure with hypercapnia, chronic obstructive pulmonary disease with acute exacerbation, heart failure, dementia, anxiety disorder major depressive disorder, dysphagia, type 2 diabetes mellitus with diabetic nephropathy, and acute kidney failure.Resident R6's Minimum Data Set, dated [DATE REDACTED] documents a BIMS score of 15, indicating Resident R6 is cognitively intact. On 09/30/25 at approximately 7:00 AM, Resident R6 was observed being taken back to her room from a shower covered with a towel and not dressed. On 10/22/25 at 7:40 AM, Resident R6 stated, even if the CNA's waited long enough for the water to warm up in the shower, the shower room was cold and really cold after your shower. Resident R6 stated, there were times CNA's would take you back to your room without being dressed. 5. Resident R10's admission Record documents an admission date of 05/22/25 with diagnoses including: type 2 diabetes mellitus with ketoacidosis, malignant neoplasm of left kidney, severe protein calorie malnutrition, nausea, anemia, chronic diastolic heart disease, muscle wasting and atrophy, dysphagia, iron deficiency, obesity, overactive bladder, body mass index of 32.0-32.%, and long term use of insulin.Resident R10's MDS dated [DATE REDACTED] documents a BIMS score of 14 indicating, Resident R10 is cognitively intact.On 10/23/25 at 1:12 PM, Resident R10 stated, she does not like going a taking a shower because it's cold. 6. Resident R38's admission Record documents

an admission date of 09/28/21 with diagnoses including: syncope and collapse, dementia, cerebral ischemia, paroxysmal atrial fibrillation, anemia, major depressive disorder, anxiety disorder, osteoporosis, nonrheumatic aortic valve disorder, and aneurysm.On 10/23/25 at 1:09 PM, Resident R38 who was alert to person, place and time, stated it is cold getting showers, she doesn't like it. On 10/22/25 at 2:34 PM, V47 stated, there are residents that have told her the shower room is chilly or cold especially after their shower.On 10/21/25 at 12:14 PM, V48 stated, residents have told her the shower room is cold. V48 stated, it can be cold in the shower room, she can see where the residents would find the room cold if they were wet and unclothed.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Metropolis Rehab & Hcc

2299 Metropolis Street Metropolis, IL 62960

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Potential for minimal harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on observation, interview and record review, the facility failed to maintain floors in a clean and sanitary manner. This has the potential to affect all 74 residents living in the facility.Findings include:The facility Resident Matrix dated 10/15/25 documents 74 residents reside at the facility.On 10/15/25 at 9:09 A.M., noted dried, dark colored spills the length of hall floors of 100 and 200 halls with a concentrated area of dark, dried spills near the nurses' station and a few clear liquid spills not yet dried on floors. There are also noted scattered bits of what appear to be torn paper, toilet paper and possibly what appears to be food particles on 100 and 200 halls. On 10/15/25 at 3:39 P.M., the same dark colored, dried spills noted on the floor of 100 and 200 halls near the nurse's station at the beginning of the hallway. The floors have not been cleaned yet. On 10/16/25 at 8:45 A.M., on 100 hall there are the same dried, dark spills of an unknown substance noted near the nurse's station that was first noted yesterday morning at 9:09 A.M.A resident grievance form dated 9/11/25 on behalf of Resident R3 complaining of dirty floors in Resident R3's room.On 10/15/25 at 9:31 A.M., V22 ( Family Member) stated the dining room floors have been very dirty over the past couple of months when she comes to visit her family member who is a resident at the facility. V22 stated it is not only immediately after a meal she notices the dirty floors in the large dining room. V22 states the housekeeping staff had plenty of time to clean the floors of the dining room. V22 described the dirtiness of the dining room floor being in the form of sticky substances on the floor and unidentified, dried spills on the floor. V22 stated

she has also noticed the floor around the nurse's station of 100 hall is frequently sticky and it appears not to have been cleaned recently either.On 10/15/25 at 2:14P.M., V26 (Housekeeping Supervisor) stated the facility was down about two housekeepers about one to two weeks ago causing them to be short of staff.

V26 stated the hallway floors and other common area floors were being neglected due to short staffing. V26 stated during this time the common area floors like hallways were being cleaned every other day instead of daily which was the normal expectation.On 10/15/25 at 3:37 P.M., V80 (Regional Director of Operations) stated the facility's floor cleaning machine has been down for a while, and the facility has not been able to clean the floors as thoroughly as needed, V80 stated the facility has ordered a new floor cleaning machine and it should be here next week sometime.On 10/15/25 at 3:50 P.M., V81 (District Manager) for housekeeping services company contracted for facility stated between the middle to end of September the facility lost a housekeeping and laundry staff causing the routine cleaning to fall behind.On 10/22/25 at 9:47A.M., V17 (Certified Nurses' Aide/CNA) stated the hallway floors have been dirtier over the past one to two months than when she first started working here. V17 believed the reason for the floors not being as clean as they had been in the past was because the facility was short on housekeeping staff.On 10/22/25 at 11:33 A.M., V48 (CNA) stated the hallway floors have recently been dirtier than in the past. V48 stated

the facility has been short on housekeeping staff in the past one to two months.On 10/22/25 at 9:49 A.M., V50 (Housekeeper) stated over the last one to two months the hallway floors were not being cleaned as frequently as they had in the past because some housekeeping staff had quit, and the remainder of the housekeeping staff were trying to focus on some of the more important areas like resident bathrooms, resident rooms, and shower rooms.On 10/22/25 at 9:55 A.M., V1 (Administrator) stated the hallway floors have not been cleaned as frequently as needed over the past one to two months and have been dirtier than

in the past due to being short on housekeeping staff. V1 stated there is no housekeeping policy for the facility.Review of facility's written housekeeping routes A, B, C, and D indicate all floors should be swept and mopped daily.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Metropolis Rehab & Hcc

2299 Metropolis Street Metropolis, IL 62960

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

was not told who Resident R6 was upset with or what she was upset about. V2 stated Resident R6 didn't want anyone to get in trouble. On 10/22/25 at 1:23 PM, V27 (LPN/SSD) stated she did write a grievance for Resident R6, but she couldn't remember what the details were. When asked if Resident R6 ever reported anything concerning V56, V27 stated that was probably what the grievance was about but Resident R6 would not tell her who the staff member was. V27 stated Resident R6 would never say who it was and didn't report it as abuse just that someone wasn't very nice to her. V27 wasn't sure about a CNA reporting the allegation. The facility Grievance Form dated 7/28/25 documents Resident R6 filed a grievance which included a check mark next to Staff Concern. This same form documents under Description: (Resident R6) feels as though staff member had poor customer service with her. There are no specific details documented on what the poor customer service includes. The form documents under Recommendations/Action Taken: SSD/ Social Services Director) to meet with (Resident R6) once a week x (times) 4 weeks to ensure customer service has improved. There are no SSD meetings/audits attached to this form.

Documentation regarding the SSD meeting/audits were requested from V1 (Administrator) via email on 10/27/25. V1 provided this surveyor with Resident R6's SSD progress notes dated 8/5/25 that documents, This writer met with resident at this time to follow up with her regarding recent grievance. Resident states she is doing well, and she is happy with her care in the facility. This writer provided support to resident at this time. There were no other progress notes provided to this surveyor that documented follow up regarding the grievance that was filed by Resident R6. V1 (Administrator) stated in the email that she was unable to locate any other documentation of meetings once a week for four weeks. On 10/22/25 at 3:23 PM, this surveyor reviewed

the allegation of abuse regarding V56 and Resident R6 with V1 (Administrator) and she stated she had started an investigation and spoke with Resident R6's power of attorney who reported to her Resident R6 had an issue with a nurse telling her she was ridiculous. The facility Abuse Prevention and Prohibition Policy dated 03/2025 documents, .Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. Prevention: The resident has the right to be free from verbal, mental, sexual, exploitation, or physical abuse; corporal punishment and involuntary seclusion. The owner, licensee, Administrator, employee, or agent of the facility shall not abuse or neglect a resident and must prohibit the misappropriation of resident property. Resident behaviors will be monitored for changes, which trigger abusive behaviors.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Metropolis Rehab & Hcc

2299 Metropolis Street Metropolis, IL 62960

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Based on interview, and record review the facility failed to ensure allegations of abuse were reported to the Administrator/Abuse Coordinator for 1 of 3 (Resident R6) residents reviewed for abuse in the sample of 46.Findings Include:Resident R6's admission Record with a print date of 10/01/2025 documents Resident R6 was admitted to the facility 2/6/25 with diagnoses that include acute respiratory failure, heart failure, chronic obstructive pulmonary disease, aortic valve stenosis, dementia, anxiety disorder, major depressive disorder, and cognitive communication deficit.Resident R6's MDS (Minimum Data Set) dated 8/15/25 documents Resident R6 is independent with making consistent/reasonable decisions, with no cognitive impairment documented.Resident R6's current Care Plan was reviewed with no Focus area related to abuse and/or behaviors documented.On 10/15/25 at 10:31 PM, V59 (CNA/Certified Nursing Assistant) stated Resident R6 reported V56 (Licensed Practical Nurse/LPN) told Resident R6 she was ridiculous and yelled in her face. V59 stated Resident R6 was really upset and crying when she reported it to her. V59 stated she told Resident R6 she needed to tell V1 (Administrator) when she came to work the next day. V59 stated she did not report the allegation to V1 since she didn't witness it.On 10/16/25 at 10:16 AM, Resident R6 stated

she had issues with V56. Resident R6 stated she was short of breath and scared and V56 didn't help her. Resident R6 stated

she wrote down the things V56 said to her during that time. Resident R6 showed this surveyor a piece of paper on her bedside table, and it listed these items with no times or dates listed next to them, choke on that, it's all

in your head, you can breathe if you try, you are crazy. Resident R6 stated it happened on a couple of different dates and she reported it to other unknown staff. Resident R6 was visibly upset when speaking to this surveyor regarding V56.On 10/16/25 at 2:56 PM, V51 (CNA) stated Resident R6 reported to her quite a few times (unknown dates), V56 (LPN) told her she was crazy. V51 stated Resident R6 reported V56 was verbally mean to her, and she was afraid of V56. V51 stated she reported the allegation to V1 (Administrator) and V2 (Director of Nurses). On 10/20/25 at 12:09 PM, V2 (Director of Nurses) stated she was unaware of any allegations of verbal abuse regarding V56 and Resident R6.On 10/21/25 at 11:35 AM, V1 (Administrator) stated she wasn't aware of any reports of allegations of V56 being verbally abusive towards Resident R6. V1 stated it should have been reported immediately.

V2 (Director of Nurses) who was in this same interview stated she did have staff report Resident R6 was upset with a staff member but when she talked to Resident R6 she told V2 she didn't want anyone to get in trouble.On 10/22/25 at 3:23 PM, this surveyor reviewed the allegation of abuse regarding V56 and Resident R6 with V1 (Administrator) and

she stated she had started an investigation and spoke with Resident R6's power of attorney who reported to her Resident R6 had an issue with a nurse telling her she was ridiculous.The Investigation V1 was referring to titled (name of state survey agency) documents under Initial Report: Initial: On 10/21/2025 at around 1:00 p.m., (initials of state survey agency) surveyor reported to Abuse Coordinator (V1) and Director of Nursing (V2) that resident and staff reported that (V56) was verbally abusive towards (Resident R6). Date and time of incident uncertain. Investigation immediately initiated. (V56) has been discharged since 10-2-2025 and (Resident R6) was discharged on 10-17-2025 .The facility Abuse, Prevention and Prohibition Policy dated 03/2025 documents under Investigation: Resident abuse must be reported immediately to the Administrator.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Metropolis Rehab & Hcc

2299 Metropolis Street Metropolis, IL 62960

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

reviewed with V2, V31's interview where she stated she reported the allegation and the name of the alleged perpetrator (V56) to V2. V2 stated that was not accurate. V2 stated she was not told who Resident R6 was upset with or what she was upset about. V2 stated Resident R6 told her she didn't want anyone to get in trouble.On 10/22/25 at 1:23 PM, V27 (LPN/SSD) stated she did write a grievance for Resident R6, but she couldn't remember what the details were. When asked if Resident R6 ever reported anything concerning V56, V27 stated that was probably what

the grievance was about but Resident R6 would not tell her who the staff member was. V27 stated Resident R6 would never say who it was and didn't report it as abuse just that someone wasn't very nice to her. V27 stated she didn't have information about a CNA reporting the allegation.The facility Grievance Form dated 7/28/25 documents Resident R6 filed a grievance which included a check mark next to Staff Concern. This same form documents under Description: (Resident R6) feels as though staff member had poor customer service with her.

There are no specific details documented on what the poor customer service includes. The form documents under Recommendations/Action Taken: SSD/ Social Services Director) to meet with (Resident R6) once a week x (times) 4 weeks to ensure customer service has improved.Documentation regarding the SSD meeting/audits were requested from V1 (Administrator) via email on 10/27/25. V1 provided this surveyor with Resident R6's SSD progress notes dated 8/5/25 that documents, This writer met with resident at this time to follow up with her regarding recent grievance. Resident states she is doing well, and she is happy with her care in the facility. This writer provided support to resident at this time. There were no other progress notes provided to this surveyor that documented follow up regarding the grievance that was filed by Resident R6. V1 (Administrator) stated in the email that she was unable to locate any other documentation of meetings once

a week for four weeks.On 10/22/25 at 3:23 PM, this surveyor reviewed the allegation of abuse regarding V56 and Resident R6 with V1 (Administrator) and she stated she had started an investigation and spoke with Resident R6's power of attorney who reported to her Resident R6 had an issue with a nurse telling her she was ridiculous.The Investigation V1 was referring to titled (name of state survey agency) documents under Initial Report: Initial:

On 10/21/2025 at around 1:00 p.m., (initials of state survey agency) surveyor reported to Abuse Coordinator (V1) and Director of Nursing (V2) that resident and staff reported that (V56) was verbally abusive towards (Resident R6). Date and time of incident uncertain. Investigation immediately initiated. (V56) has been discharged since 10-2-2025 and (Resident R6) was discharged on 10-17-2025 .The facility Abuse, Prevention and Prohibition Policy dated 03/2025 documents under Investigation: Resident abuse must be reported immediately to the Administrator. The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. While a facility investigation is under way, steps will be taken to prevent further abuse. If a person is identified in the allegation of abuse, that person will not be allowed access to the facility while the investigation is in progress, except to meet with the administrator as part of the investigation. The person identified in the allegation of abuse will have no contact with residents or other employees during the investigation process.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Metropolis Rehab & Hcc

2299 Metropolis Street Metropolis, IL 62960

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

was unable to complete showers on the residents that had a shower scheduled. V10 stated she tries to do

a bed bath in place of a shower if unable to do the shower, but sometimes she is unable to do the showers all together.

On 10/21/25 at 1:39 PM, V14 (CNA) stated there have been times she was unable to complete showers over the past 2 months because she's been the only CNA on the hall and unable to leave the hall to do showers.

On 10/16/25 at 10:15 AM, V2 stated two weeks was too long of a period between showers. V2 stated all residents should have a shower or bed bath at least two times per week at the minimum. V2 said the facility staff may have forgotten to document the showers for the residents listed above for the time periods pointed out but confirmed there was no proof of them receiving showers/baths and no evidence of refusals for those time periods. V2 stated there was no facility policy for showers.

On 10/29/25 at 8:11 AM, V1 (Administrator) stated she was unable to explain the gaps in showers for residents Resident R4, Resident R5, Resident R7, and Resident R22. V1 did state Resident R7 frequently refused bed baths but was unable to explain why there was no documentation of bathing or refusal of bathing for Resident R7 in the gaps with no documentation of showering or refusal of one. V1 stated she believes those residents were at least offered the opportunity to bathe and facility staff were not documenting the attempts of showering/bathing, but she agreed if there was no documentation then the attempts of or actual showers could not be verified. V1 stated 6 days was too long to go between showering/bathing for the residents. V1 stated residents should at least be offered

the opportunity to shower/bathe twice per week at the minimum.

The facility Grievance Form dated 8/6/25 documents, .Description: Staff have not had towels for showers for two mornings. Below To Be Completed By Staff, Investigation: I found some bath towels (and) washcloths in (name of resident) old room yesterday. Summary/Findings: I found some washcloths in the room between big n (sic) small shower rooms. Then I also found some washcloths in room [ROOM NUMBER]B closet earlier. I found a bath towel (and) another washcloth in 402A bed (and) bathroom when I deep cleaned.

Recommendations/Action Taken: Spoke with (name of Laundry Supervisor) to ensure laundry is being completed in the evening as scheduled. New towels (and) washcloths ordered. Date Resolved: 8/7/25.

Person Notified of Resolution: Staff.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Metropolis Rehab & Hcc

2299 Metropolis Street Metropolis, IL 62960

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

refused her dressing changes to her legs including application of the ace wraps, but remembered it was frequently Resident R7 did refuse. V53 stated the reason given from Resident R7 for frequently refusing her dressing changes was because she wanted the nursing staff to do it a certain way including rubbing nystatin powder or cream into her open wounds on her legs and then dressing them. V53 stated she explained to Resident R7 couldn't do that because it wasn't the doctor's orders. V53 stated when she would explain this to Resident R7 she would then refuse

the dressing all together. V53 stated she did not notify the medical doctor when Resident R7 would refuse her dressing changes because it was in the evening and Resident R7 refused frequently. V53 stated there were shifts

she was working when there were no ace wraps in the building she knew of. V53 stated she would not notify V2, DON or the wound nurse immediately, but would leave a note on the shift report in the electronic health record system and let them know that way. V53 stated she would expect them to find the notificat

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Metropolis Rehab & Hcc

2299 Metropolis Street Metropolis, IL 62960

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

any fortified pudding with her lunch. 7. Resident R19's admission Record documents an admission date of 12/22/23 with diagnoses including: end stage renal disease, dementia, dependence on renal dialysis, gastro-esophageal reflux disease without esophagitis, combined systolic and diastolic heart failure, dysphagia, and cognitive communication deficit.Resident R19's MDS dated [DATE REDACTED] documents a BIMS score of 06, indicating severe cognitive impairment. Section GG documents Resident R19's eating ability as set up or clean up assistance needed. Resident R19's Order Summary Report documents a dietary order of no added salt diet with mechanical soft texture with an order date of 04/18/25 and no end date listed. Resident R19's order summary report documents a dietary supplement order of fortified foods every day and evening shift with an order date of 03/31/25 and no end date listed.Resident R19's Care Plan documents a focus area of Resident R19 has a swallowing problem dated 02/03/25 with interventions including: diet to be followed as prescribed dated 10/01/24, monitor for shortness of breath, choking, labored respiration, lung congestion dated 10/01/24, and monitor/document/report to nurse/dietitian and physician as needed for difficulty swallowing, holding food in his mouth, prolonged swallowing time, repeated swallows per bite, coughing, throat clearing, drooling, and pocketing food in mouth dated 10/01/24. Resident R19's care plan does not include a focus area of nutrition.Resident R19's dietary note dated 10/18/25 at 11:56 AM documents: dietitian chart review for weight trends. October weight was 127.2 pounds and BMI 24.8 % weight is 127.2 - 136.4 pounds since 2/2025. At review overall trends within UBW (usual body weight) range since admission. No pressure wounds and lab review on 09/19 notes glucose 181.5 which is elevated. Diet order has been individualized based on intake trends. Regular with regular texture, sugar free condiments

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Metropolis Rehab & Hcc

2299 Metropolis Street Metropolis, IL 62960

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

of Nurses/DON) stated the facility pharmacy is in a different regional state and Gabapentin is considered a controlled substance in that state. V2 stated the physician (Medical Director) wasn't submitting the prescriptions to the pharmacy and that is why the residents went without their medications. V2 stated she called the physician, and he was coming to the facility in 2-3 days to see the residents. V2 stated the physician told them to call the on-call doctors who told the facility they could only write the prescriptions for 2-3 days since they didn't see the residents routinely. V2 stated she also contacted the physician services company, and they told the physician to write the prescriptions. V2 stated V74 (Nurse Practitioner) who sees the residents at least weekly, did not have a controlled substance license so was unable to write those prescriptions. V2 stated the pharmacy was attempting to come up with a solution to the problem and had made her an authorized signer for the narcotics prescriptions. V2 stated if the medication is in the emergency kit they can get them from there. V2 stated the agency nurses don't have access to them but if

they needed something the on-call nurse could come get it for them.On 10/22/25 at 3:23 PM, V1 (Administrator) stated she had talked about getting a local pharmacy to have as a backup for medications that needed to be filled immediately.On 10/28/25 at 12:27 PM, V74 (Nurse Practitioner/NP) stated she was aware the facility was having issues keeping controlled substance/pain medications available for the residents. V74 stated she didn't have a Controlled Substance License and the Medical Director was supposed to be filling all controlled substances. V74 stated Gabapentin is not a medication you can stop without tapering it down. V74 stated it is approved to be used to treat pain, but it also has other intended uses that can cause sodium imbalances which can cause increased confusion. V74 stated she had brought

this to the facilities attention during meetings she had with them. V74 stated it had been an issue since she started seeing residents at the facility (several months). V74 stated Lyrica is like gabapentin. V74 stated if someone who is taking an opioid routinely doesn't get it that can trigger opioid withdrawl symptoms. V74 stated the facility has always had the option to call the on-call physician and get three days' worth of medications anytime a resident is out. V74 stated they can call every three days until they are able to get a full supply of the medications in.The facility Pain Management policy dated 2/2025 documents, .It is the policy of this facility to respect and support the resident's right to optimal pain assessment and management. This facility recognizes the residents may have decreased sensations or perception of pain.

Chronic pain may produce anorexia, lethargy, depression, immobility, social isolation.Strategies for pain management include but are not limited to.Pharmacological interventions.routine pain medication, as needed pain medication.All resident care providers will provide information to the resident and the resident's family/significant others that optimal management of pain is a primary goal of resident care, and is consistent with the mission and core values of this facility.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Metropolis Rehab & Hcc

2299 Metropolis Street Metropolis, IL 62960

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

they should be working on shift in the building. V45 stated it happened about 2 weeks ago. V45 stated she was working 300 hall and there were 2 agency CNAs that left at approximately 8:40 PM and did not return until it was time to clock out at 10pm.

On [DATE REDACTED] at 3:23 PM, V1 (Administrator) stated they have agency staff working to cover staff call-in's. V1 stated they should always have three CNA's working night shift and they are meeting the minimum staffing ratios.

The Posting Direct Care Daily Staffing policy dated 12/2024 documents, Policy: 1. The facility will post the staffing on a daily basis at the beginning of each shift. The actual hours worked per position and the total number of hours worked will be posted.

The facility Resident Matrix dated [DATE REDACTED] documents 74 residents reside at the facility.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Metropolis Rehab & Hcc

2299 Metropolis Street Metropolis, IL 62960

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

top of the medication cart, but they leave them unattended in residents rooms. V61 stated when he sees them, he always takes them to a nurse because he doesn't want another resident to take them.On 10/16/25 at 2:56 PM, V51 (CNA) stated he didn't know V85 (Agency RN) but V56 (LPN) and V53 (LPN) leave medications unattended on top of the medication cart and in resident rooms.On 10/20/25 at 11:44 AM, V62 (CNA) stated nursing staff leave medication on residents bedside tables for the resident to take. V62 stated

the pills just sit unattended on the table.On 10/21/25 at 2:38 PM, V2 (Director of Nurses) stated it was not acceptable for medications to be left unattended.The (name of regional pharmacy) Policy and Procedure Manual 2024 (dated July 2024) documents in section 5.1: Drug Administration--General Guidelines procedure step 14 During routine administration of medications, the medication cart is kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept

on the top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. Under Tips for Safe Medication Administration documents 1. Maintain security of provided medications. A. Cart must always be visible to nurse administering medications.C. Never leave a medication in a resident's room without orders to do so.The facility undated Medication Administration Policy for Senior Living documents, Adherence to this Medication Administration Policy is essential to ensure the well-being and safety of our residents. All staff members are expected to follow these guidelines strictly and to report any issues or deviations from the policy.S. Residents who self-administer must have a profile only MAR which lists their medications & indicates that they self-administer.1. Medications should be stored in a secure, locked area with restricted access to authorized personnel only.3. Medications should be administered according to the five rights of medication use: right resident, right drug, right time, right dose, and the right route. 4. Staff members must ensure that residents have swallowed or otherwise received the medication properly. S. Self-administration of medications will be supported for those who have written orders from an authorized healthcare provider and can demonstrate that they are capable of safely administering their medications through a self-administration evaluation upon admission, every 6 months, and as needed.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Metropolis Rehab & Hcc

2299 Metropolis Street Metropolis, IL 62960

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

medications would be administered late. V53 stated she administers medications to approximately 40 residents each shift.On 10/21/25 at 2:38 PM, V2 (Director of Nurses) stated she didn't know why medications were administered late. V2 stated she administers medications at the facility, and she can administer them timely unless there was another issue. V2 stated if a resident falls or she had to send someone to the hospital then timely medication administration would be an issue.On 10/22/25 at 3:23 PM, V1 (Administrator) stated she would expect medications to be administered according to the current guidelines. V1 stated medications should be administered within one hour before or after the times the medications were ordered.On 10/28/25 at 12:27 PM, when asked about medications being administered late, V74 (Nurse Practitioner) said she had talked with staff about administering insulin as ordered. V74 stated she is at the facility every week. V74 stated every morning blood sugar tells her what the nighttime dose of insulin is doing. V74 stated giving that insulin late really affects things. When asked about the effect late administration has on a resident, V74 stated, as a prescriber, I don't know that it is given late. V74 stated she then adjusts the dosage of their insulins, so the worst-case scenario is hypoglycemia. V74 stated

the residents blood sugar is going to bottom out. V74 stated she was very frustrated with the facility and wasn't sure why they weren't prioritizing resident care. This surveyor reviewed with V74 other medications that were administered late and V74 stated if a diuretic isn't administered until noon the onset of action would be 4-5 pm. That is when someone with Sundowner's would start exhibiting symptoms and could fall attempting to take themselves to the bathroom.The undated facility Medication Administration Policy for Senior Living documents, Adherence to this Medication Administration Policy is essential to ensure the well-being and safety of our residents. All staff members are expected to follow these guidelines strictly and to report any issues or deviations from the policy. Continuous improvement and open communication are encouraged to uphold best practices in medication administration. Medication Administration.3. Medications should be administered according to the five rights of medication use: right resident, right drug, right time, right dose, and the right route.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Metropolis Rehab & Hcc

2299 Metropolis Street Metropolis, IL 62960

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Based on interview, observation, and record review the facility failed to ensure the facility employed certified dietary staff in the kitchen. This failure has the ability to affect all 74 residents residing at the facility.Findings include: On 09/29/25 at 11:03 AM, V5 (Cook) stated they do not currently have a Dietary Manager. V5 stated, she does not have her food manager certification, and that no one in the kitchen currently does. V5 stated, she has been back for a couple days now, she worked at the facility a while ago.On 09/29/25 at 11:33 AM, V1 (Administrator) stated, there is currently no one in the kitchen that has their food manager certification. V1 stated, they do not currently have a Dietary Manager, the previous one (V4) walked out approximately a couple weeks ago. V1 stated they did not get any of the current staff certified within that time frame. V1 stated, they have someone from the dining services they use doing the ordering and menu but they are not at the facility daily.On 09/29/25 at 11:03 AM there were no certified dietary staff at the facility or working in the kitchen.The facility Resident Matrix dated 10/15/25 documents 74 residents reside at the facility.The facility document dated 07/07 titled, Sanitation Certification documents: policy: The food service manager shall be certified in sanitation. Additional food service staff (usually the cooks) are certified

in sanitation thus ensuring that the facility has someone in-house that is certified in sanitation during the hours of operation for the food service department. Procedure: 1 county health departments and local community colleges provide training for management sanitation certification examination. 2 at least one individual in the food service department will be certified for sanitation during the hours of operation for the department. 3 certification will be kept current and renewed as directed.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Metropolis Rehab & Hcc

2299 Metropolis Street Metropolis, IL 62960

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

at 3:50 PM, V21(Family) stated, meals have been late lately. About a week ago he left the facility about 1:15 PM and Resident R8 still had not received her lunch. He was on the phone with her and she received her lunch at approximately 2:00 PM.On 09/29/25 at 11:33 AM, V1 (Administrator) stated, all the previous dietary staff walked out a couple weeks ago. That morning a couple nurses and CNAs cooked breakfast for that day and

the next day. V1 stated, she and some others cooked lunch and dinner the first day and by the second day

they were able to get some agency staff in for lunch and dinner time. The residents did get three meals every day, the first day they did get peanut butter and jelly sandwiches and oatmeal. On 09/30/25 at 3:40 PM, V1 stated, meal service has been late sometimes, they are working on it.On 09/30/25 at 11:40 AM, V10 (Certified Nurse Aide/CNA) stated, the kitchen has been struggling to get meals out supposedly due to not having the supplies they need and the staff they need. Meals had been coming out as late as 2:00 PM.

The meals have been better but they can still be later than scheduled. V10 stated, it is not uncommon for

the trays to come out missing all the condiments and they are not given a basket of them for the hall trays or anything like that.On 09/30/25 at 10:52 AM, V8 (CNA) stated, a few weeks ago dietary had a lot of call ins then all the dietary staff walked out on Sunday morning at 6:30 AM. From what she heard, the staff walked out because there was no gas to cook with, there was no air conditioning in the kitchen and they were trying to make meals under those conditions and they were buying some items out of their pockets.

There was a meeting with the administration and they walked out after the meeting. V8 stated, that Sunday V1's husband, some nurses and CNAs went into the kitchen and cooked. That Sunday morning the residents were served peanut butter and jelly sandwiches and oatmeal. They did not have any other options for food that Sunday. Some residents did get some fruit also. They did not serve any cereal that day. V8 stated, she does not believe the residents received the supplements or double protein, or other items they were supposed to receive that day. V8 stated, she had to take some of the peanut butter and jelly sandwiches back to the kitchen to get them pureed. V8 stated, she believes a CNA was able to figure out how to puree the food. She believes for lunch they had baked chicken, vegetable and etc for lunch. V8 stated, food was late on that Sunday. V8 stated, food has come out late on days since then also. V8 stated, some of the food was not served until after 2:00 PM. V8 stated, the food trays today did not have any condiments on them, the food tray typically have not had condiments on them.On 09/30/25 at 1:46 PM, V15 (Licensed Practical Nurse) stated, she worked the day the peanut butter and jelly sandwiches were served for breakfast. The CNAs and nurses realized they had not been called for drink carts and realized the dietary staff left. Some of the nurses and CNAs went into the kitchen and fixed PB & J sandwiches and oatmeal for breakfast. The residents probably did not get the supplements and other-directed items but they did the best they could with there being no dietary staff. V15 stated, the substitutions were lacking for a bit, but she thinks they were doing the best they could. The food was late that day. Since that day, kitchen staff has still been missing supplements and not reading the tickets carefully. Food has been late since then also, some days are better than others.On 10/15/25 at 3:43 PM, V18 (Dietary) stated, they do not have time to read the bottom of the tickets or get items the staff are coming to the dietary door during meal service to get.The facility Resident Matrix dated 10/15/25 documents 74 residents reside at the facility.The undated facility policy titled, Dining Service Meal Times documents: meals will be served no more than 30 minutes

after the scheduled meal times.The undated facility policy titled, General Dining Experience residents will have an exceptional dining experience that enhances their quality of life and provides attention to the individual resident's plan of care and dining wishes.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Metropolis Rehab & Hcc

2299 Metropolis Street Metropolis, IL 62960

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

there being no dietary staff. The food was late that day, but she thought everyone liked the lunch and dinner. Since that day, kitchen staff has still been missing supplements and not reading the tickets carefully.

Food has been late since then also, some days are better than others.On 09/30/25 at 3:50 PM, V21(Family) stated, there have been multiple missing items from Resident R8's food. The dietary ticket rarely matches what food

she receives. V21 stated, he has even asked the CNAs about why items were missing from the food tray and they have told him it is the kitchen. Not too long ago they ran out of milk.On 10/21/25 at 2:55 PM, V88 (Dietary Manager) stated, the menus print off strange sometimes, if the dietary ticket states they are supposed to get butter and jelly, they should receive it. If they have toast they should receive something to put on it like butter or jelly or if they receive a hamburger, they should receive ketchup and mustard. On 10/27/25 at 12:45 PM, V72 (Registered Dietician) stated, she would expect the menu to be followed, if the facility was out of an item she would expect a substitution of equal nutritional value to be given.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Metropolis Rehab & Hcc

2299 Metropolis Street Metropolis, IL 62960

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

alert to person, place and time, stated the toast is really hard and it crumbled when he pushed on it and there is no butter or jelly for it and he doesn't have time to wait for anything, he was supposed to be at a doctor's appointment at 8:00 AM but apparently they wrote it down wrong and he is late because no one is ready to take him and he hopes he doesn't miss it all together. 7. On 09/30/25 at 10:36 AM, Resident R12 who was alert to person, place and time stated, breakfast was not that warm today and the toast was kind of burnt. 8.

On 09/30/25 at 7:58 AM, Resident R10 stated, the eggs are not warm Resident R10's MDS dated [DATE REDACTED] documents a BIMS score of 14 indicating, cognitively intact.9. On 09/30/25 at 8:22 AM, Resident R11 picked up her toast, looked at both sides, looked around her tray, tapped the toast on her plate and set it back down without eating any. Resident R11's toast appeared burnt and hard. Resident R11's tray did not contain any butter or jelly.On 10/18/25 at 2:20 PM, Resident R11 was alert to person, place and time, stated they have talked about the food concerns in the resident council meetings including the food being cold or burnt.10. On 09/30/25 at 8:50 AM, Resident R12 who was alert to person, place and time, stated she would like butter and jelly for the toast today, but the toast was kind of burnt and hard anyways.11. On 09/30/25 at 9:10 AM, Resident R14 who was alert to person, place and time, stated the food for breakfast was cold this morning, that is not the first time. 12. On 09/30/25 at 9:11 AM, Resident R25 who was alert to person, place and time, stated breakfast was cold this morning, it was not great. This is not the first time food has been cold. 13. On 09/30/25 at 9:13 AM, Resident R15 who was alert to person, place and time, stated breakfast was cold this morning, it has not been great lately. On 09/30/25 at 10:52 AM, V8 (CNA) stated, there was a lot of toast that was burnt and hard today. V8 stated, there have been other days the toast has been burnt and the sausage burnt and other items have been cold.On 09/30/25 at 11:40 AM, V10 (CNA) stated, the kitchen has been struggling to get meals out supposedly due to not having the supplies they need and the staff they need. V10 stated, the residents have complained about the food to her including things being burnt, hard, or cold.On 10/22/25 at 2:12 PM, V88 (Dietary Manager) stated, he believes the morning and afternoon staff are doing far better but he is still working on permanent evening and weekend staff and hopefully that will help the situation. The undated facility policy titled, Monitoring Food Temperatures for Meal Service documents in part: meals that are served on room trays may be periodically checked at the point of service for palatable food temperatures. Food temperatures of hot food on room trays at the point of service are preferred to be at 120 degrees Fahrenheit or greater to promote palatability for the resident.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Metropolis Rehab & Hcc

2299 Metropolis Street Metropolis, IL 62960

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

are. V88 stated, he is going to see if they can get it moved up on the resident's tickets and printed bigger.The undated facility policy titled, General Dining Experience documents: residents will have an exceptional dining experience that enhances their quality of life and provides attention to the individual resident's plan of care and dining wishes. 4. meals will be served at the appropriate texture and consistency to meet the individuals plan of care, but not limiting the right to make personal choices. 5 residents will be treated as guests and with proper respect. Staff members serving in the dining room will offer person centered care to each resident. 6 staff serving and assisting in the dining room will consider allergies and intolerances and honor food and beverage preferences as much as possible.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Metropolis Rehab & Hcc

2299 Metropolis Street Metropolis, IL 62960

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

will just say no and shut the door.On 09/30/25 at 3:20 PM, V18 (Dietary) stated, if they have the item such as pudding, they give it, if they do not they don't. On 09/30/25 at 3:21 PM, V19 (Dietary) stated, they do not have time to read the bottom of the tickets.On 09/30/25 at 3:50 PM, V1 (Administrator) stated, she knows

the dietary staff were not doing well about reading the bottom of the dietary tickets where the supplements and preferences are listed. V1 stated she will talk to them again.On 10/15/25 at 3:43 PM, V18 stated, they do not have time to read the bottom of the tickets or get items the staff are coming to the dietary door

during meal service.On 10/27/25 at 12:45 PM, V72 (Registered Dietician) stated, she would expect all the supplements to be given as she recommended for weight loss and wounds.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Metropolis Rehab & Hcc

2299 Metropolis Street Metropolis, IL 62960

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0809 Level of Harm - Minimal harm or potential for actual harm

On 10/15/25 at 3:43 PM, V18 stated they do not have time to read the bottom of the tickets or get items the staff are coming to the dietary door during meal service and get. Meals will be served no more than 30 minutes after the scheduled meal times.

Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Metropolis Rehab & Hcc

2299 Metropolis Street Metropolis, IL 62960

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Based on interview, observation, and record review the facility failed to keep equipment functioning properly to ensure sanitation of dishware. This failure has the potential to affect all 74 resident residing at the facility.Findings include:On 09/29/25 at 11:07 AM, V6 (Dishwasher) stated, he has only worked at the facility for a few days, he worked at the facility years ago. V6 stated, he does not know where the strips to check

the sanitizer in the dish machine are. V6 stated, he does not know when it was checked last. On 09/29/25 at 11:14 AM chlorine test strips to check the sanitizer in the dish machine were found, the strips did not perform any color change when utilized, indicating no sanitizer was reading on the strip.On 09/29/25 at 11:14 AM there was no liquid in the line running from the sanitizer container to the dish machine. V6 tried purging the sanitizer line to pull sanitizer from the container of sanitizer to the dish machine, and no sanitizer was observed moving in the line to the dish machine.On 09/29/25 at 11:38 AM, V6 stated, he has

the dish machine sanitizer working now.On 09/29/25 at 11:38 AM, V6 rechecked the sanitizer in the dish machine, the sanitizer read approximately 75 ppm (parts per million) chlorine. V6 stated, it should read between 50 and 100 ppm chlorine. V6 stated, he has never documented anything for the dish machine on

the dish machine log because the numbers did not make sense to him, so he just left it alone. On 09/29/25 at 11:33 AM, V1 (Administrator) stated, she is not for sure when the dish machine was checked last, and

she did not know the sanitizer was not reading properly. After reviewing the facility document titled, Dish Machine Log dated September 25, V1 stated she was not sure what the sanitizer should read. V1 stated,

she does not know why there has not been any documentation on the log since the 24th of September and

before the 24th it appears whoever filled it in was just following suit of the numbers before theirs. V1 stated,

they have not changed sanitizer in the kitchen.The facility document titled, Dish Machine Log dated September 25 documents under the PPM column 200 for breakfast, lunch, and dinner for date 1 - 23, for date 24 the PPM under the breakfast heading, 200 is documented. The facility Resident Matrix dated 10/15/25 documents 74 residents reside at the facility.The undated facility policy titled, Dish Machine Operation documents: The dining services maintain the operation of the dish washing machine according to established procedure and manufacturer guidelines posted or contained in this guideline to ensure effective cleaning and sanitizing of all tableware and equipment used in the preparation and service of food.

Procedure: 1 all dishwashing machines should be operated according to manufacturer recommendations.

Tableware, utensils, and posts and pans should be cleaned and sanitized in either a high - temperature dishwashing machine that uses hot water, or a chemical sanitizing machine that uses a chemical sanitizing solution. 2 check the dishwashing machine each morning before first set of dishes are to be washed. This is usually before the breakfast meal and again in the PM or generally before the supper meal. If the dishwashing machine has not been used for several hours, it is generally recommended to allow the dishwashing machine to cycle for one or two cycles to allow dishwashing machine to come up to proper function. If a chemical sanitizer is used, check the concentration using the correct test tape for type of sanitizer in use.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Metropolis Rehab & Hcc

2299 Metropolis Street Metropolis, IL 62960

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

administration sooner of the problem. V3 stated the facility is currently waiting on a quote from a company to replace the entire system.On 10/20/25 at 12:25 P.M., V2 (Director of Nurses) stated there is a call light in Resident R29's bathroom that needs to be repaired. V2 stated she wasn't aware of the call light in Resident R29's bathroom not working until this morning. On 10/20/25 at 3:28 P.M., V2, DON stated the facility has no policy on call light system.On 10/21/25 at 1:48 P.M., V2, DON stated the facility has placed a literal bell in Resident R29's bathroom until the facility is able to make the repairs or replace the call light system. On 10/20/25 at 1:01 P.M., V1 stated she was not aware of Resident R29's call light in his bathroom wasn't working until this morning. V1 stated the facility is putting a literal bell to place in the bathroom of Resident R29's bathroom to use until they can get his call light fixed. V1 stated she was going to call the company who they have contracted for their call light system to see when they can come look at it. V1 stated the facility has no call light policy. On 10/30/25 at 9:19 A.M., V83 (Regional Director Maintenance) stated he was made aware of the call light system not functioning in some areas of the building about 2 weeks ago by V3 and V1. V83 stated he was not made aware of any specific areas where the call light system was not working, but only knew there were some general areas where it wasn't working. V83 stated he is currently waiting on one more bid for having the call light system replaced and then will move forward with getting that replacement scheduled.Facility's undated maintenance job description states the maintenance personnel will check light bulbs, exit lights, room temperatures, circuit breakers, temperatures in all coolers and freezers, and nurse call systems and makes all necessary adjustments and repairs. Facility's maintenance job description also states the maintenance personnel will maintain electrical and mechanical equipment in good working order.

Event ID:

Facility ID:

If continuation sheet